Get documents about "Peripheral Intravenous Cannulation The Royal Free Hampstead NHS septicaemia
Document Sample
The Royal Free Hampstead NHS Trust
Peripheral Intravenous Cannulation
Clinical Guidelines and Procedures
Adult and Children’s Services
August 2009
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 1 of 34 CF & SMcK August 2009
Validation Grid
Title Peripheral intravenous Cannulation clinical guideline
and procedures
Primary Author Caterina Falce Matron, Immunology and
Transplantation
Steve McKenna Lecturer Practitioner Child Health
Target Audience Medical Practitioner, Nurses and Midwives, Allied
Health Care Professionals.
Service Group Trust-wide
Commissioning body Clinical Practice group
Stake holders consulted Clinical Practice group
Directorates:
Specialist Services, Transplant and Immunology,
Urgent Care, Trauma and Managed Networks, Private
practice, Cannulation team
Clinical Practice / Advanced
Advance Practice
Practice
Associated Policies / Consent Policy
Documents Infection Control Guidelines, Intravenous Sodium
Chloride 0.9% flushes
NMC “The Code: Standards of conduct, performance
and ethics for nurses and midwives”
Guideline Replacement Cannulation - procedures for adult peripheral
intravenous cannulation 2007
Paediatric Cannulation & Phlebotomy Workbook 2009
Date of submission August 2009 Update
Date of Review August 2011
Key words PIC, Aseptic Technique, Documentation, Children and
Young People, Adult
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 2 of 34 CF & SMcK August 2009
Validation Grid .................................................................................................................. 2
1. Introduction ............................................................................................................... 5
2. Aim ............................................................................................................................. 5
3. Staff who can undertake the procedure .................................................................. 5
3.1 Qualified Nursing and Midwifery staff who may undertake this procedure ........... 5
3.2 Criteria for application to undertake nurse cannulation ........................................ 5
3.3 Training pathway for nursing and midwifery staff ................................................. 6
3.4 Previous experience in cannulation ..................................................................... 6
4. The role and responsibility of nominating managers ............................................ 6
5. Documentation .......................................................................................................... 6
6. Non-registered staff who may undertake this procedure ...................................... 6
7. Supervised practice guidelines ............................................................................... 7
7.1 To support supervised practice the following criteria must be met ....................... 7
8. Criteria to be an Assessor and Assessment Guidelines for Intravenous
Peripheral Cannulation .................................................................................................... 7
8.1 Guidelines for assessment ................................................................................... 8
9. Peripheral Intravenous Cannulae available at the Royal Free .............................. 9
9.1 Gauge Size ............................................................................................................. 9
10.1 Recommendations for Cannula Choice - 2 ........................................................ 11
11 Best practice Recommendations:.......................................................................... 11
11 Improving venous access- dilating the veins ....................................................... 12
11.1 Best practice Recommendations: ...................................................................... 12
12. Considerations when selecting the Vein ........................................................... 12
13. Consent ................................................................................................................ 13
14. Equipment Required ........................................................................................... 14
15. Use of a needless system ................................................................................... 14
16. Procedure ............................................................................................................. 14
17. Procedure for caring for PIC............................................................................... 15
18. Flushing PIC......................................................................................................... 17
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 3 of 34 CF & SMcK August 2009
19. Aims of securing the device with a dressing .................................................... 17
20. Removal of PIC .................................................................................................... 18
Criteria for Cannula removal ......................................................................................... 18
21. Procedure for Removal of PIC ............................................................................ 18
22. Potential problems and complications of Peripheral Intravenous
Cannulation: ................................................................................................................... 18
22.1 Missed Vein ....................................................................................................... 19
22.2 Haematoma ....................................................................................................... 19
22.3 Infiltration and Extravasation .............................................................................. 19
22.4 Inflammation and infection: ................................................................................ 19
22.5 Infusion Phlebitis and Thrombophlebitis ............................................................ 20
22.6 Cellulitis.............................................................................................................. 20
22.7 Bacteraemia ....................................................................................................... 20
22.8 Septicaemia ....................................................................................................... 20
22.9 Pain .................................................................................................................... 21
22.10 Psychological problems .................................................................................. 21
23 References ........................................................................................................... 21
24 Appendix 1 Certificate of Competence for Peripheral Intravenous
Cannulation (PIC) ........................................................................................................... 25
25 Appendix 2 Veins of the Forearm ............................................................................ 28
26 Appendix 3 Phlebitis Scale Chart ............................................................................ 28
27 Appendix 4 Extravasation Scale Chart .................................................................... 28
28 Appendix 5 Patients Requiring Chemotherapy ...................................................... 29
29 Appendix 6 High impact intervention audit forms…………………………...……….28
30 Appendix 7 Equality impact assessment ................................................................ 28
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 4 of 34 CF & SMcK August 2009
1. Introduction
Peripheral intravenous cannulation (PIC) is a skilled process that involves a number of
stages and is increasingly being performed by nurses in a variety of clinical settings
(Scales 2005). Intravenous therapy is an indispensable part of treatment for many
patients (Parker 1999); Therefore developing knowledge and skills through training in the
insertion and care of peripheral intravenous cannula is vital (Castledine 1996).
In response to increased freedom provided within the Scope in Practice (NMC 2005) and
the The Code (NMC, 2008) there has been a move for nurses and midwives to cannulate
(Inwood 1996). A number of factors need consideration when introducing cannulation into
an organisation or department (Jackson 1997; and Scales 2005). It is the aim of these
guidelines to address these considerations.
2. Aim
The aim of cannulation is to insert a peripheral intravenous cannula (PIC) by maintaining
peripheral intravenous devices safely, including patency of lines and prevention of
complications during insertion and maintenance.
3. Staff who can undertake the procedure
Medical practitioners
Nurses and Midwives including Heath Care Assistants (HCA) following training and
competency assessment
Cannulation team members following training and competency assessment
3.1 Qualified Nursing and Midwifery staff who may undertake this procedure
Peripheral intravenous cannulation (PIC) is considered to be an advanced practice within
this Trust. An advanced practice may be defined as an aspect of care which may be
undertaken by registered nurses/midwife/cannulation team and who have undergone the
specified training and assessment, accept accountability for their actions and feel
competent to undertake the aspect of care. PIC is considered a practice that every
midwife is expected to demonstrate competency in following registration.
3.2 Criteria for application to undertake nurse cannulation
The opportunity for registered practitioners, HCA‟s to perform cannulation exists to
provide continuity of care. In response to the increased freedom provided within Scope of
Practice (NMC 2005), nurses require a sound basic theoretical knowledge to be able to
perform such a technique.
There is little evidence to quantify how much practice is required to become competent in
cannulation, but experience suggests that two issues are important:
1. initially a high level of exposure is required to learn the skills
2. regular practice (at least once per week) is required to maintain the skills
It is only appropriate to develop nurses‟ roles if:
1. the development is in the best interest of the patient
2. skills, knowledge and competencies are maintained
3. nursing practice is not fragmented or compromised by the development of this
practice
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 5 of 34 CF & SMcK August 2009
This means that the introduction of nurse cannulation must be carried out in appropriate
areas by trained nurses, midwives, health care assistants and other health care
professionals and must not disrupt delivery and continuity of nursing care.
3.3 Training pathway for nursing and midwifery staff
Before staff undertakes assessment for this practice they must have completed the
following steps:
1. Agreed with their line manager/ PDN (Practice Development Nurse) during their
SDR that it is appropriate to take on this practice as part of their role
2. To undertake this training staff must be prepared to commit time to the
achievement and maintenance of competencies.
3. Have an identified mentor and assessor (with advice from line manager or the lead
nurse for quality and development) and must be within their own department
4. Be assessed as competent in practice intravenous drug administration according
to Trust policy
5. Complete the distance learning workbook and attend the Royal Free workshop on
peripheral intravenous cannulation within a 3 months timeframe.
6. Gain supervised practice with a member of staff who is an assessor (see section 4)
If the nurse moves to another clinical area it is the responsibility of the practitioner to
discuss with their line manager whether continuing with cannulation in the new work
environment is still in the best interest of the patient.
3.4 Previous experience in cannulation
If the practitioner has previous experience in cannulation in another trust, he/she must
produce evidence to their manager/PDN and will be at the manager‟s discretion to assess
if the practitioner requires full training in accordance with the PIC training at the Royal
Free Hampstead NHS trust.
4. The role and responsibility of nominating managers
By nominating a member of staff to undertake cannulation training the nominating
manager is agreeing to support their staff by protecting the time they need to work with
their mentor/assessor.
5. Documentation
In line with the NMC (2005, 2008) guidelines on standards for records and record keeping
there must be a current and appropriate plan of care for each patient. The plan must
incorporate on-going evaluation and reassessment of care and evidence that relevant
interventions and observations have been communicated to appropriate members of the
multidisciplinary team.
On insertion of a cannula the following should be documented:
name of the practitioner inserting the cannula
insertion site
size of cannula
date of insertion
6. Non-registered staff who may undertake this procedure
Non-registered staff may also undertake training and assessment for this practice, as long
as it is appropriate to take on this practice as part of the role for which they have been
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 6 of 34 CF & SMcK August 2009
employed to do. Non-registered staff must follow the same training pathway as for
nursing staff with the exception of being trained in intravenous drug administration. These
staff will be nominated from specific clinical areas by their managers. Before they
undertake the assessment they must have completed the following steps:
1. Be nominated by their line manager
2. Have an identified mentor and assessor
3. Attend a workshop on peripheral intravenous cannulation
4. Gain supervised practice with the mentor/assessor
5. The requirement of undertaking PIC should be contextual to the clinical area in
which the practitioner is working.
6. Receive training in the use of Patients Groups Directive for the use of
intravenous saline flushes.
7. Supervised practice guidelines
Supervised practice is the period of training and supervision, under the direction and
leadership of a mentor/assessor. Following a period of observation and learning in liaison
with your mentor/assessor, together you will take a joint decision about when you are
ready to commence your practice.
7.1 To support supervised practice the following criteria must be met (nurses and
miwives only)
Be a registered practitioner with a minimum of one years post registration
experience
Be competent in the advanced practice of peripheral intravenous cannulation for a
minimum of 6 months
Carry out advanced practice of peripheral intravenous cannulation on a regular
basis
When supporting supervised practice you should sign the student‟s supervised
practice record everytime you observe them in practice
8. Criteria to be an Assessor and Assessment Guidelines for Intravenous
Peripheral Cannulation
Assessment has been defined by Nicklin and Kenworthy (2000) as a “measurement that
directly relates to the quality of learning and as such is concerned with student progress
and attainment”.
A nursing assessor must fulfil the following criteria:
Be a registered practitioner at band 6 or above
Provide evidence that they have completed a course that incorporates the
principles of assessment and supervision of practice
Be competent in the advanced practice of peripheral intravenous cannulation for a
minimum of 6 months
Have been assessed as competent in cannulation and undertake cannulation on a
regular basis (i.e. 2 to 3 times per week)
The assessor can nominate a PIC supervisor to support the staff member during
their PIC training. He/she must have a minimum of 6 month experience in PIC,
working within the clinical area, being competent and up to date in accordance to
trust policies. However the supervisor cannot complete the assessment process.
To assess non-nursing staff the assessor must meet he following criteria:
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 7 of 34 CF & SMcK August 2009
Provide evidence that they have completed a course that incorporates the
principles of assessment and supervision of practice e.g. NVQ assessors course
A1 or equivalent
Be competent in the advanced practice of peripheral intravenous cannulation for a
minimum of 6 months
Have been assessed as competent in cannulation and undertake cannulation on a
regular basis (i.e. 2 to 3 times per week)
The assessor can nominate a PIC supervisor to support the staff member during
their PIC training. He/she must have a minimum of 6 month experience in PIC,
working within the clinical area, being competent and up to date in accordance to
trust policies. However the supervisor cannot complete the assessment process.
Each registered practitioner is accountable for his/her actions or omissions (NMC, 2008).
As an assessor your judgement may be questioned if a practitioner whom they assessed
as competent makes a mistake because they were clearly not competent to carryout
peripheral intravenous cannulation.
Assessing competence means that it is not sufficient that the practitioner merely
demonstrates manual dexterity and good clinical skills. They must also demonstrate an
understanding of the underlying theory that supports their practice. This involves giving
clear rationale for their actions. It is implicit upon the practitioner, once assessed as
competent, that they are clear of the limitations of undertaking the procedure and those
circumstances where it may be inappropriate for it to be undertaken.
It is up to the assessor and the practitioner to decide when the assessment should take
place. The setting should be that in which the practitioner usually practices.
If you are in any doubt as to the individuals‟ competence you should suggest that the
practitioner is reassessed at a future date. You can then discuss the areas of weakness
that need to be improved upon and devise an action plan.
The assessment criteria (certificate of competence) are retained by the practitioner for
personal reference, but a copy of the assessment criteria is given to the individuals‟ line
manager (paediatric staff – original document to be kept in file at ward/department level
and photocopy of the same document given to the PDN).
If you have any questions regarding assessment of this advanced practice please contact
the Nursing Directorate ext 35554.
8.1 Guidelines for assessment
Arrange an initial meeting with the assessor presenting your completed workbook.
Appoint a supervisor at the initial meeting if necessary
Set up a plan of action and intermediate interview at 6 weeks
Aim for final assessment around week 12.
To carry out an assessment you must:
Set a date to meet with the practitioner to complete the practical assessment. All
sections of the assessment criteria (certificate of competence) must be completed.
You must observe a minimum of 5 PIC carried out by the practitioner. Where
possible the observations should be of a number of different insertion sites and if
possible, a selection of different patient groups.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 8 of 34 CF & SMcK August 2009
Once the practitioner has demonstrated competence, the assessor can sign the
certificate of competence
It should be remembered that all practitioners are ultimately accountable for their
own practice and should only carry out practice that is within their sphere of
competence.
Once a practitioner has completed a competency assessment, it remains the
responsibility of the individual practitioner to remain clinically and professionally
up-to-date.
Practitioners will need to provide evidence of continued professional development
at their staff development reviews; this can be achieved though the completed
competency or attendance at a cannulation update session (see training
department for details).
9. Peripheral Intravenous Cannulae available at the Royal Free
Introcan safety non ported/winged IV cannula available trust wide
Neoflon ( Neonates and Paediatrics)
Introcan safety non ported/non winged IV cannula (Theatres)
Vasofix safety ported IV cannula (Theatres speciality use)
Some cannulas not specified may be available in speciality areas for specialty use;
please see local guidelines.
9.1 Gauge Size
Scales (2005) recommends using the smallest gauge needle and shortest length into the
most accessible peripheral vein, with the largest diameter and the greatest blood flow,
which would allow for satisfactory administration of the therapy.
Smaller gauge cannulas are less likely to cause a through puncture of the vein and allow
increased blood flow around the catheter thus diluting irritant drugs. They have less
chance of causing phlebitis and thrombus.
Larger gauge cannula rub against the intimae of the vein and may precipitate the
development of phlebitis thus decreasing blood flow around the cannula
Gauge Colour Length Uses And Considerations Comments
when large volumes of fluid must be infused large vein required
14 Orange 2 inch trauma patients insertion is painful
patients for major surgery
pregnant women
16 Grey 2 inch may be used for adolescents and adults
rapid infusions (often used in theatres)
surgical patients large vein required
blood transfusions of more than 4 units insertion is painful
blood components, TPN & other viscous fluids
18 Green 1 ¾ inch may be used for older children, adolescents & adults
Use a larger gauge in a larger vein to infuse caustic or
viscous solution
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 9 of 34 CF & SMcK August 2009
may be used for adolescents & adults commonly used
suitable for most intravenous infusions and up to 4
20 Pink 1 ¼ inch units of blood
patients requiring IV fluids/drugs but not surgical
intervention
suitable for most infusions including red cells, easier to insert in small
plasma and clear fluids thin fragile veins
may be used for infants, toddlers & children slower flow rates must
22 Blue 1 inch
adolescents, adults - esp. the elderly be maintained
difficult to insert into
tough skin
Neonates, infants, toddlers Requires extremely
Adolescents, adults (esp. elderly) with small veins small veins e.g. fingers,
lower portion of inner
24 Yellow ¾ inch Suitable for most infusions but with slower flow rates
arms
including chemotherapy
May be difficult to insert
into tough skin
Cannulas for blood transfusion:
Standard intravenous cannulas are suitable for blood component infusion. All blood
components can be slowly infused through small bore cannulas or butterfly needles e.g.
21 G. For rapid infusion, large bore cannulas e.g. 14 G are needed.
Handbook of Transfusion medicine 4th edition, Editor DBL McClelland, TSO, London
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services.
Page 10 of 34 CF & SMcK August 2009
Recommendations for Cannula Choice - 2
Gauge Colour Uses & Considerations Comments
19 Ideal for cannulation on a hand, finger or inner The steel needle once removed leaves
beige aspect of a wrist if access is poor a small plastic cannula
can be used for once only bolus injections at The cannula are small, sharp & short
21 doctors request if access is poor Cannula are easy to insert
Butterfly green
Cannula
16-24 23
blue
25
orange
Can be used for once only bolus injections at Not to be used for chemotherapy,
doctors request in special circumstances even if single dose
Steel Steel needle is inflexible & can cause trauma &
Butterfly infiltration
Generally only used for phlebotomy
11 Best practice Recommendations:
When possible avoid veins that are:
on the dominant arm/hand
too superficial
thrombosed or fibrosed
directly over joints - particularly the cubital fossa region which is used for blood
sampling & interferes with arm flexion
tortuous, bruised or infected
in oedematous limbs
in an area of extensive scarring e.g. healed burns
in limbs with lymphoedema
near a previous haematoma
in an arm with an arteriovenous shunt or fistula
in areas of skin inflammation, disease or breakdown
below a previous IV infiltration/phlebitis site
hardened or sclerotic
on the inner wrist or arm as they are small and thin walled
uncomfortable for the patient
difficult to secure
For patients with renal problems, consideration when selecting veins should be
given to patients without a shunt who may need one in the future.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 11 of 34 CF & SMcK August 2009
11 Improving venous access- dilating the veins
It is necessary to dilate a vein in order to insert a PIC. The application of a tourniquet
should promote venous distension, however light tapping of the vein may be used, but not
too hard as this can be painful. The use of rubber gloves is highly inappropriate
(Dougherty 1996).
There is little supporting literature about how to apply the tourniquet. Jackson (1997)
suggests that the tourniquet is applied 10 cm above the insertion site. Dougherty (1996)
adds that it should be tight enough to restrict venous return, but not to affect arterial flow.
Additionally, opening and closing of the fist forces blood into the vein, causing them to
distend (Dougherty 1996). A good „rule of thumb‟ is to place 3 fingers under the tourniquet
during application.
However in Children‟s Services a second person using their hand can be an effective way
to engorge the vein thus facilitating a sufficient blood flow/amount.
11.1 Best practice Recommendations:
1. If cannulating the forearm apply the tourniquet above the elbow
2. If cannulating the forehand apply the tourniquet below the elbow
3. Tap the veins lightly to encourage dilation
4. Ask the patient to gently open and close their fist (excessive fist clenching has been
reported as causing pseudo hyperkalaemia
5. Use gravity to encourage dilation of the veins
6. Emla is not licence for use under 1 years old, however Ametop can be used on any
age and takes 30 minutes post application to be effective (cream should be removed
after 1 hour to prevent skin from burning) the effect of the cream will last up to 5
hours
7. If these measures are unsuccessful, remove the tourniquet and apply heat e.g. bowl
of hand warm hot water to promote blood flow and aid vein dilation.
12. Considerations when selecting the Vein
A knowledge of anatomy and physiology is essential, both for the selection of a site for
cannulation and the prevention of intravenous-related problems. The individual should be
able to distinguish a vein from an artery. The inadvertent administration of intravenous
drugs into the arterial system may seriously compromise the circulation to the involved
limb (Jackson 1997). Veins do not have a pulse and empty with digital pressure (Jackson
1997).
Palpation of the vein is important in determining the condition of the vein. Dougherty
(1996) lists criteria for a good vein:
are bouncy & soft
are well supported
refill when depressed
are visible & straight
have a large lumen
Some research suggests those cannulaes located over mobile joints (without
immobilisation of the joint with a splint) are more at risk of phlebitis and extravasation
(Jackson 1997). However Stonehouse & Butcher (1996) found no correlation between
phlebitis and cannula inserted near a joint, but 65% of patients complained of discomfort
and restricted movement.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 12 of 34 CF & SMcK August 2009
Dougherty (1996) discovered that patients value the time that nurses spend finding the
appropriate vein. Moreover they appear to gain a sense of control from being asked their
preference of vein to cannulate.
Veins suitable for peripheral intravenous cannulation include those on the dorsum of the
hand and the cephalic and basilic veins of the forearm (Jackson 1997). The vein should
be well supported.
The selected vein should be suitable for the fluid prescribed. Small vessels will not
accommodate large volumes of fluid or irritant solutions.
The vein should be situated on the distal part of the patient‟s limb, but proximal to
previous attempts (Terry et al 1995).
Jackson (1997) highlights two potential problems following distal insertion:
Irritant substances may be routed past an area of inflammation, thereby prolonging
the inflammation process
Leakage from the primary site; this will cause extravasations injury if vesicant
substances are used.
The veins of the antecubital fossa should be preserved for venous sampling (Jackson
1997) and veins in the feet should be avoided due to the increased risk of deep vein
thrombosis (Jackson 1997). In addition the vessel should not show any signs of
thrombosis or bruising (Jackson 1997).
At times it will be necessary to insert a cannula in a scalp vein or feet. This should only be
undertaken by competent skilled practitioners (paediatricians, paediatric nurse
practitioners and emergency physicians).
13. Consent
Prior to the insertion of a PIC, the patients‟ verbal consent must be obtained, (Scale,
2005). It is also important to provide an explanation of the reason for cannulation,
duration of the intended therapy and associated risks (Scales, 2005, NMC 2002). It is
important to ensure that adequate information is provided to the patients so that they can
make an informed decision. In the event that the recipient of the cannula does not
understand English, it is incumbent upon the health practitioner to engage an appropriate
translator (not a family member) to ensure that the above discussion takes place and it
clearly documented in the medical record.
Consent to cannulate a child/ young person must be obtained from the person who has
parental responsibility, biological mother always has parental responsibility unless
removed by the court ( Children‟s Act, 1989 and 2004)
13.1 Legal and Ethical Issues Related to PIC:
The patient has the right to refuse to have a PIC. You may try to obtain their consent by
gentle reassurance and explain the reasons for a PIC. However the patient‟s choice is
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 13 of 34 CF & SMcK August 2009
final. If a patient refuses to have a PIC inform, the doctor who ordered the insertion of a
PIC.
If patient cannot speak English, an interpreter is required to positively identify the patient.
In relation to children and young people, parental consent will be sought.
14. Equipment Required
Ametop ® / Emla ® cream Clinell ® wipe (alcoholic 2%
Cannula choice as per table 10.2 Chlorhexidine)
DisposableTourniquet Gloves & plastic apron
Cannulation IV pack 5mls Sodium chloride 0.9% (prescribed)
Alcohol gel hand rub & 10ml syringe
Needless system extension Tegaderm IV (3M) dressing
80.5 litre portable sharps bin
15. Use of a needless system
The needle less system is a needle free, closed IV access system. It provides improved
staff safety as it reduces the number of needles used and reduces the risk of staff coming
into contact with blood. Risk of infection is also reduced as the system is closed with a
self sealing bung.
This system can be used with all peripheral cannulae with and without an extension
16. Procedure
Intervention Rationale
Explain the procedure to the patient To obtain consent and co-operation
® ®
Offer Ametop Emla Local anaesthetic cream applied 30 minutes
prior to painful procedure
Whenever possible, undertake cannulation Provide a clean, calm environment
in the treatment room
Wash hands and put on apron, assemble Prevent cross infection
and prepare necessary equipment. Flush
needless system extension). To prevent air embolism
Examine arms for suitable location of To identify most suitable vein to cannulate
cannula
Discuss choice of vein with patient (if Inform selection of cannula site
appropriate) and obtain verbal consent.
If hair removal necessary and patient Reduce the risk of inflammation at the
consents, clippers should be used. Do not cannulation site
shave.
Pack Preparation To minimise risk of infections use aseptic
technique
Place patient in a comfortable position with Aids patient safety and comfort.
the chosen limb supported by a pillow.
Wash hands, put on non-sterile gloves. Gloves are used as part of universal
Only use sterile gloves if the patient is precautions except in neutropaenic patients
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 14 of 34 CF & SMcK August 2009
neutropaenic. where they are required to protect the
patient.
Apply a tourniquet to arm to dilate veins by Provide easy access to vein
obstructing venous return
Clean the skin for at least 30 seconds with To reduce risk of healthcare associated
Clinell® wipes (alcoholic 2% infection
Chlorhexidine)to cover a 1 inch radius and
allow to dry
Gently pull the skin taut below the proposed To anchor and immobilise the vein
insertion site.
Insert the cannula smoothly at a 30o angle
to the skin and level off as soon as the back
flow of blood appears.
Advance the catheter hub into the vein To ensure cannula advanced along the
keeping the needle in a stationary position vein.
looking for a flashback of blood along the
catheter (this may not always happen).
Remove tourniquet and dispose into the To prevent build up of blood leading to
yellow bag haematoma and prevent infection
Apply two strips of sterile tape from the To anchor the cannula
dressing (see diagram)
Apply pressure on the vein beyond the To minimise leakage of blood while
needle and then remove the needle by removing the needle.
holding the catheter hub in place.
Attach the needless system bung Reduces need to manipulate cannula
Check for flashback of blood and then flush To ensure the vein is cannulated and that
with 5 mls of normal saline 0.9% the cannula is cleared of blood.
Cover insertion with TegadermTM dressing. Provide details for ongoing care
Sign and date the dressing
In children and young people splints as To stabilise cannula site
supported with bandages are applied.
Anchor the needless system connector with Prevent pulling on vein
tape
Dispose of sharps in the sharps bin, waste To reduce risks of contamination and
into yellow clinical waste bag, remove sharps
gloves and apron and wash hands.
Record cannulation in nursing record Provide ongoing evaluation
17. Procedure for caring for PIC
Intervention Rationale
Ensure date, time and site of insertion and To provide information for evaluation and
any nursing interventions related to the maintain accountability
cannula are recorded in the patient‟s
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 15 of 34 CF & SMcK August 2009
nursing notes
Aseptic technique must be used at all times To prevent introduction of pathogens
when caring for the cannula and during
drug/fluid administration
Cannula must be anchored securely using Prevents trauma to the vessel wall and
the sterile strips from the Tegaderm 3M IV dislodgement of the cannula.
dressing. The insertion site must not be
obscured. Giving sets must be anchored
securely using tape, e.g. Micropore. (Berry
et al, 1986. Davidson, 1986 & Ringer,
1987).
If patient has a bath or shower check To protect cannula and prevent
integrity and waterproof dressing and contamination of the dressing
change as appropriate
The cannula must also be protected if the
patient has a bath or shower.
The site should be dressed with Tegaderm Provides a sterile, vapour permeable
3M IV dressing and ensures the insertion site is
easily observed
The dressing must be replaced and site Moist environments should be prevented as
cleaned with Clinell ® wipe (alcoholic 2% they encourage the growth of pathogens
Chlorhexidine) using an aseptic technique,
if moisture or blood are present under the
dressing
Cannula used intermittently should be To prevent cannula blocking
flushed 6 hourly with Sodium Chloride 0.9%
which must be prescribed or by using PGD
( Patient Group Directive ) if applicable
Following the administration of a bolus drug To ensure the whole dose is given
the flushing solution should be given over Reducing the risk of irritation
approx. 30 seconds appropriate to the drug
that was administered unless otherwise
indicated. In certain circumstances cannula
should not be flushed after drug
administration i.e. Iloprost- (please see
individual protocols)
If a drug is administered using an infusion To ensure the rate of drug administration is
line, the rate of administration of the not exceeded.
flushing solution should not exceed the rate
at which the drug was administered
The cannula should be observed during Early detection of problems and prevention
each interaction with the patient. If the of consequences
patient complains of pain or has any signs
of phlebitis or extravasation use the
following scales (see appendix 3 and 4) to
record the severity of the problem and
determine action required. Incident form
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 16 of 34 CF & SMcK August 2009
needs to be completed.
Following a blood transfusion the PIC To minimize the risk of embolus infusion
should be flushed immediately.
Document interventions in the appropriate To maintain accountability and record
12 hours cannula document in the in-patient keeping.
booklet
Note: If the cannula is being used for Parental Nutrition administration, then a 5mg GTN
patch must be placed distal to the cannula and changed daily.
18. Flushing PIC
18.1 Indications for flushing
6 hourly to maintain patency or before use to verify the patency of an IV cannula if
it is not being used continuously
Between IV drug administrations to prevent drug interactions
After initial cannula insertion to prevent clotting in the cannula
To clear the cannula after a drug or infusion has been administered
Note: If a cannula is being used for the administration of parenteral nutrition, it does not
need to be flushed between infusions. It only needs to be flushed when there is a planned
break between PN bags or at the end of the therapy.
18.2 Solutions for flushing
Sodium Chloride 0.9% is the commonly used fluid for flushing IV cannula. However, it is
not compatible with all drugs so check for potential interactions. Refer to the ward
pharmacist if there are any queries.
Water for injection should only be used where it is specifically required to prevent
interactions as it damages red blood cells.
A 10ml syringe is recommended when administering a 5 ml flush to reduce the pressure
in the vein. (Juan 1993)
19. Aims of securing the device with a dressing
After insertion the cannula should be covered with a sterile dressing to reduce the risk of
contamination. Jackson (1997) suggests that the dressing should:
keep the cannula secure
allow easy inspection of the insertion site
keep the cannula site clean and prevent entry of bacteria
be easy to apply and remove
prevent the build up of moisture beneath the dressing
Should the dressing become loose or contaminated it must be replaced.
The continuing care of the cannula is an integral part of the nurse‟s role. To identify early
signs of intravenous problems the cannula should be checked before any additives or at
minimum 12 hourly (Jackson 1997).
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 17 of 34 CF & SMcK August 2009
20. Removal of PIC
Criteria for Cannula removal
cannula should be changed every 3rd day however in children and young people
change as necessary ( Bregenzer et al 1998, Webster et al, 2008)
Blocked cannula
Evidence of extravasation
Evidence of phlebitis/infection
Redundant cannula (no longer required)
21. Procedure for Removal of PIC
Equipment required: Cotton wool or gauze
Disposable gloves and apron Waterproof sterile dressing
Sterile dressing pack
Intervention Rationale
Discuss plans to remove cannula with the Patient informed about plan of care
patient
Collect required equipment, wash hands, Reduce infection risks
put on gloves
Remove the cannula using an aseptic Prevent the introduction of pathogens
technique
Hold a piece of dry cotton wool or gauze To prevent damage to the vein (Dougherty
over the insertion site and remove the 1999)
cannula carefully, using a slow steady In neutropenic patients sterile gauze must
movement and keeping the hub parallel to be used.
the skin
Apply pressure until bleeding stops Prevent blood loss and bruising
Clean the site with sterile saline (if Prevent pathogens entering whilst the site
necessary) and dress with a waterproof heals
elastoplast dressing.
If phlebitis or extravasation has been Prevent further complications
diagnosed, plan further intervention as per
scale. (see appendix 3 and 4)
Request insertion of new cannula if required To continue IV treatment
Document removal of cannula in patient To provide a record and baseline for
notes noting reason for removal observation
22. Potential problems and complications of Peripheral Intravenous Cannulation:
Jackson (1997) and Hindley (2004) list potential problems associated with peripheral
intravenous cannulation:
Missed vein
Haematoma
Infiltration
Extravasation
Infection
Thrombus
Infusion phlebitis
In addition pain and psychological problems are also associated.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 18 of 34 CF & SMcK August 2009
22.1 Missed Vein
There are several reasons why a vein may be missed during the insertion procedure:
Inadequate vein anchoring/stretching allows the cannula tip to push the vein aside.
Failure to recognise when PIC has gone through the opposite vein wall – will be indicated
by diminished blood flow.
When stopping too soon after the PIC insertion, so that only the stylet and not the PIC
enter the lumen of the vein. This becomes apparent when blood return disappears when
the styled is removed.
When inserting the PIC too deep, below the vein. This is evident when the cannula will
not move freely because it is embedded in muscle. The patient may complain of severe
discomfort.
Failure to penetrate the vein wall because of improper insertion angle (too steep or too
flat) causing the cannula to ride on top of or below the vein.
22.2 Haematoma
Haematoma is caused by raised intravascular pressure when the tourniquet is not
released promptly and the vein is cannulated.
Or when the vein has been punctured during the insertion process but missed (see
above)
22.3 Infiltration and Extravasation
Refer to non-cyto guidelines in the Clinical Practice Manual.
22.4 Inflammation and infection:
“Peripheral intravenous cannula insertion will be carried out by trained and competent
staff using strictly aseptic techniques” (DoH, 2003).
More than 60% of patients admitted to hospital are likely to receive therapy via an
intravenous device (Wilson, 2001). With so many patients undergoing treatment via
peripheral cannula, nurses have a professional duty to recognise and prevent associated
complications, acting always to “protect and support the health of individual
patients/clients” (NMC, 2002).
Infections associated with the peripheral intravenous cannula are intrinsically linked with
commensal skin flora (Hindley 2004).
The most frequent life threatening complication is septicaemia, caused either by the
device used for vascular access or from contamination of the infusate administered (Maki
et al, 1991). Skin flora and cross infection by patients and staff are factors involved in
cannula related Staphylococcus infections. It is thought that skin organisms may be
introduced into the wound at the time of the insertion of the peripheral cannula or later
when organisms migrate along the interface between catheter and tissue (Maki et al,
1991).
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 19 of 34 CF & SMcK August 2009
There are several types of inflammation or infection associated with IV cannula, which
may be minimised if strict asepsis is used throughout the life of the cannula and the IV
site is closely monitored (Pratt et al, 2007).
These have been classified as:
22.5 Infusion Phlebitis and Thrombophlebitis
Phlebitis is defined as the acute inflammation of a vein wall by chemical or mechanical
irritation with subsequent complications of infection and thrombosis (Stonehouse &
Butcher, 1996, Parker 1999, Hindley 2004). Mechanical irritation occurs when the cannula
rubs against the vein wall, while chemical irritation is due to drugs or intrinsic
contamination of fluids (Dougherty, 1997). Patient discomfort can often be the first
indication of complications such as phlebitis.
Phlebitis scales measure the severity of phlebitis in terms of local redness, pain, swelling
and the development of a palpable venous node (Stonehouse & Butcher 1996; Wilson
2001).
The size of the cannula and the device design are also important considerations when
considering phlebitis (Dougherty 1996). In a pilot study to test new aspects of IV
management Stonehouse & Butcher (1996) found that larger cannula lumen appeared to
increase the likelihood of mechanical phlebitis (Stonehouse & Butcher 1996).
Additionally, the use of large cannula causes more pain than the smaller devices.
Therefore the smallest suitable cannula should always be selected and situated in the
largest vein possible. This combination will allow for efficient haemodilution of substances
that are administered intravenously (Jackson 1997), thus reducing the incidence of
phlebitis.
The composition of the cannula material is also shown to reduce the incidence of
phlebitis. Cannula made of Vialon have less surface defects and prevent adhesion of
platelets and proteins (Kerrison and Woodhall 1994). Additionally Vialon absorbs water
thus increasing its plasticity and reducing the incidence of phlebitis (Kerrison and
Woodhall 1994; Jackson, 1997). Moreover, 90% of patients reviewed by Stonehouse &
Butcher (1996) preferred Vialon for comfort.
22.6 Cellulitis
This can be defined as the Inflammation of the skin tissue caused by invading bacteria
such as staphylococcus aureus. It is characterised by local heat, redness, pain and
swelling. Fever and general malaise may also be experienced.
22.7 Bacteraemia
Bacteraemia is the presence of bacteria in the blood (demonstrated by blood culture) in
the absence of systemic signs of sepsis. Potentially is caused by introduction of
pathogens to an IV site. This may occur in various ways such as poor asepsis during
insertion, “tracking” down the cannula from skin surface, or through poor technique when
using the cannula.
22.8 Septicaemia
Systemic infection in which pathogens are present in the circulating blood stream having
spread from an infected focus e.g. infected PIC site with associated clinical signs and
symptoms
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 20 of 34 CF & SMcK August 2009
The best therapeutic measure when an infection occurs or is suspected is to remove the
cannula this not only negates the infective cause but, also simultaneously protects the
lumen from further physiochemical trauma (Hindley 2004)
22.9 Pain
The cannulation procedure is often painful. Topical anaesthetic agents can reduce the
pain of peripheral intravenous cannulation (Scales 2005). Topical anaesthetic cream has
to be applied two hours prior to cannulation. This is not always practical and has
vasoconstriction properties which may further complicate cannulation (Gunwardene &
Davenport 1990). However the use of a fast acting cream is a good alternative as it is
effective after 10 minutes and has mild vasodilatation effects (Scales 2005). It is also
advised by Scale (2005) that local anaesthetic should be removed before cannulation
because prolonged skin contact has been associated with skin damage
22.10 Psychological problems
The fear of pain, needles and injections is a common phenomenon among the general
population which can become exaggerated when people are ill (Castledine 1996; Davies
1998). Anxiety can exacerbate the pain and trauma of the procedure and may lead to
non-compliance and refusal to treatment (Davies 1998). Fainting and refusal of life saving
treatment are labelled as a phobia and need prompt recognition and management.
In order to prevent phobias acquired by conditioning, the insertion of the cannula should
be undertaken by someone who has acquired skill through constant practice.
Technical confidence, minimising pain, diversion distraction, relaxation techniques and
good communication skills all help to reduce the stress associated with IV cannulation
(Dougherty 1996).
23 References
Berry, R. Franecki, M. & Sunser, S. (1986) Abstract of presentation, NITA Conference,
May. New Orleans, USA
Bregenzer, T.et al, (1998) Is routine replacement of peripheral intravenous catheters
necessary? Archives of internal medicine 26:158(2): 151-6
Cahill, M (1991) Clinical Skillbuilders – IV Therapy. Springhouse Corporation.
Springhouse, Pennsylvania.
Castledine, G. (1996) Nurses‟ role in peripheral cannulation. British Journal of Nursing, 5,
20, 1274.
Creamer E (2000) Examining the care of patients with peripheral venous cannulas. British
Journal of Nursing 9 (20) 2128-2144
Davies, S. (1998) The role of nurses in intravenous cannulation. Nursing Standard,
January 14, 12, 17, 43 - 46.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 21 of 34 CF & SMcK August 2009
Davidson, L. (1986) Dressing subclavian catheters. Nursing Times. Feb. 12, 82, 40.
Department of Health (2001) Reference Guide to Consent for Examination or Treatment.
The Stationery Office, London
Department of Health (2003) Saving lives. The Stationary Office, London
Department of Health (1989 and 2004) Children‟s Act. London
Dibble, SL et al (1991) Clinical Predictors of Intravenous Site Symptoms. Research in
Nursing and Health, 14: 413 – 420
Dougherty, L. (1996) Intravenous cannulation. Nursing Standard, 11, 2, 47 - 54.
Dougherty, L. (1997) Reducing the risks of complications in IV therapy. Nursing Standard,
12 (5) 40 – 42
Dougherty, L. (1997) reducing the risk of complications in IV therapy. Nursing Standard,
October 22, 12, 5, 40 - 42.
Hindley G (2004) Infection Control in peripheral cannula. Nursing Standard. 18,27, 37-40
Inwood, S. (1996) Designing a nurse training programme for venepuncture. Nursing
Standard, February 14, 10, 21, 40 - 42.
Jackson, A. (1997) Performing peripheral intravenous cannulation. Professional Nurse,
October, 13, 1, 21 - 25.
Kerrison, T. & Woodhull, J. (1994) Reducing the risk of thrombophlebitis: a comparison of
Teflon and Vialon cannula. Professional Nurse, 9, 10, 662 - 666.
Maki, DG & Ringer, M. (1991) Prevention of Infection associated with central venous and
arterial catheters. Journal of the American Medical Association. 258.
Maki, D. et al (1991) Prospective randomised trial of povidone-iodine, alcohol, and
chlorhexadine for prevention of infection associated with central venous and arterial
catheters. Lancet, 338, 8763, 339 - 343.
Morbidity and Mortality Weekly Report (2002) Guidelines for the Prevention of
Intravascular Catheter-Related Infections. 51 (10) 1-36
NMC (2002) Code of professional conduct Nursing & Midwifery Council. London
NMC, (2005) Scope in Practice. Nursing & Midwifery Council. London
NMC, (2005) Guidelines for records and record keeping. Nursing & Midwifery Council.
London
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 22 of 34 CF & SMcK August 2009
NMC, (2008) The code: Standards of conduct, performance and ethics for nurses and
midwives. Nursing & Midwifery Council. London
Parker L. (1999) IV Devices and related infections: British Journal of Nursing. 8: (22)
1491-1498
Peters, JL et al, (1984) Peripheral venous cannulation: reducing the risks. British Journal
of Parenteral Therapy. 5 56 – 58
Pettit & Hughes (1993) Intravenous Extravasation: Mechanisms, Management and
Prevention. Journal of Perinatal and Neonatal Nursing. March 69 – 79
Pratt, RJ et al, (2007) Epic 2: National Evidence-Based Guidelines for Preventing
Healthcare-Associated Infections in NHS in England. Journal of Hospital Infection. 65S:
S1-S64.
Royal College of Nursing Infection Control Association (1994) Intravenous Line Dressings
– Principles of Infection Control. RCN. London
Sedgewick, J. (1997) We must assess the care we give: nursing practices in invasive
procedures. Professional Nurse, 5, 11, 624 - 630.
Shoal, J. & Oliver, S. (1992) Efficacy of Normal saline injection with and without heparin
for maintaining intermittent Intravenous sites. Applied Nursing Research, 5 (1): 9 – 12
Scales K (2005) Vascular access: a guide to peripheral venous cannulation. Nursing
Standard 19 (49): 48-52
Stonehouse, J. & Butcher, J. (1996) Phlebitis associated with peripheral cannula.
Professional Nurse, October, 12, 1, 51 - 54.
Terry, J., Baronowski, L., Lonsway, R., Hendrick, C. (1995) Intravenous therapy: Clinical
Principles and practice. Philadelphia, W.B. Saunders.
United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) The
Scope of Professional Practice. London, UKCC.
Webster,J. et al (2008) Routine care of peripheral intravenous catheters versus clinical
indicated replacement. BMJ:337:a339
Wilson, JE (1991) Preventing Infection during IV therapy. Professional Nurse, July: 388 –
392
Wilson, J. (1994) Prevention of infection during IV therapy. Professional Nurse, 9, 6, 388 -
392.
Wilson J. (2001) Infection Control in Clinical Practice. Second Edition. London Bailliere
Tindall.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 23 of 34 CF & SMcK August 2009
Wood, L. (1993) IV Vesicants: How to avoid extravasation. American Journal of Nursing.
April, 42 – 46
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 24 of 34 CF & SMcK August 2009
24 Appendix 1 Certificate of Competence for Peripheral Intravenous Cannulation (PIC)
Peripheral Intravenous Cannulation (PIC)Supervised Practice Assessment Criteria
Performance criteria Met Not Met
Knowledge
Is able to describe the normal anatomy & physiology of the venous system
Demonstrate understanding of the various cannula sizes which may be requested
List the criteria used for choosing the vein for PIC
Explain how to choose the correct equipment for PIC
Describe the potential complications of PIC and the appropriate action to take
Skills
Assesses and plans appropriate care in conjunction with the patient/client giving
appropriate information, and maintaining dignity and comfort throughout the
procedure
Chooses the appropriate equipment and prepares the environment appropriately
Demonstrates ability to choose an appropriate site and vein
Demonstrates use of the principles of infection control
Use of aseptic technique
Is able to deal with potential problems
Demonstrates safe handling of body fluids and disposal of sharps & waste
Awareness/Attitude
Registered Nurses: Recognises own competency level and can explain
implications of accountability when undertaking an advanced practice
Non-registered staff: Recognises need to maintain competence through practice
and further education where needed.
All - Recognises the individual needs of the patient/client and deals with them
sensitively
Date Supervised Practice Comments Signature
1
2
3
4
5
6
7
8
9
10
Date Formal assessment comments Signature
I feel I have received sufficient theoretical knowledge and supervised practice to undertake the
advanced practice of peripheral intravenous cannulation
Name of practitioner:
Signature Of Practitioner: Date:
This practitioner has successfully met all the criteria for assessment
Name of assessor:
Signature Of Assessor: Date:
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 25 of 34 CF & SMcK August 2009
25 Appendix 2 Veins of the Forearm
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 26 of 34 CF & SMcK August 2009
26 Appendix 3 Phlebitis Scale
Phlebitis Scale
Score Criteria Action
No pain At IV site, no No action
erythema ( redness ), no
0 swelling, no induration,
no palpable venous cord
Painful IV site, with or Continue to use IV cannula
without erythema, no but observe site for
1+ swelling, no induration, changes
no palpable venous cord
Painful IV site with Remove cannula, clean
erythema and swelling, and dress site, inform
and with induration or a medical staff, document
2+
palpable venous cord < 3 action
inches above the IV site
Painful IV site with Remove IV cannula, clean
erythema, swelling, and dress site, continue to
induration and a palpable observe site, inform
venous cord > 3 inches medical staff, document
3+ above the IV site. action
Infusion may have
stopped running due to
thrombosis. Pus may be
present
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 27 of 34 CF & SMcK August 2009
27 Appendix 4 Extravasation Scale Chart
Extravasation Scale
Score Criteria Action
No evidence of infiltration No action
0
at IV site
Mild infiltration with an Stop infusion, remove
area of extravasation cannula, elevate limb,
measuring <1‟‟ x 1‟‟ and dress site, observe for
1+
<2‟‟ x 2‟‟ changes, inform medical
staff, complete incident
form
Moderate infiltration with Stop infusion, remove
an area extravasation cannula, elevate limb,
measuring >1‟‟ x 1‟‟ and dress site, observe for
2+
2‟‟ x 2‟‟ changes, inform medical
staff, complete incident
form
Severe infiltration with an Stop infusion, remove
area of extravasation cannula, elevate limb,
measuring >2‟‟ x 2‟‟ dress site, observe for
3+ changes, inform medical
staff, complete incident
form
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 28 of 34 CF & SMcK August 2009
28 Appendix 5 Patients Requiring Chemotherapy
Past Medical History
Axillary node clearance or lymphoedema - Do not use this limb to cannulate
because of poor venous/lymphatic return and an increased risk of infection.
For similar reasons, patients with Superior Vena Cava Obstruction (SVCO) have a
higher risk of extravasation, and the medical team should be consulted. These
patients should not receive cytotoxics peripherally.
Treatment
Chemotherapy administered peripherally should only be given via cannula and no
other venous access devices e.g. butterfly cannula (see North London Cancer
Network Guidelines for the Safe Prescribing, Handling and Administration of
Cytotoxic Drugs for further information).
If a patient has poor venous access a central venous access device should be
considered, for example, a Hickman line. Alternatively a PICC line or Porto-cath may
be appropriate.
The vein should be situated on the distal part of the patient‟s limb, but proximal to
previous attempts. This reduces the risk of extravasation around the primary
leakage site (see guidelines). For similar reasons be aware of venepuncture sites in
the antecubital fossa. Use the other limb if necessary.
Cytotoxic agents range in classification between non-irritant, irritant and vesicant
substances. When a vesicant is to be administered veins between the wrist and the
elbow should be used. However, do not use the antecubital fossa for administering
cytotoxic agents, as there is an increased risk of extravasation. Ideally dorsal, radial
and ulna veins should not be used for vesicants; they tend to be superficial and
fragile veins and so have a higher risk of extravasation. Good veins should be used
for irritant and vesicant veins. Most common are; Median cubital, basilica and
cephalic veins.
Additionally, avoid thrombosed or fibrosed veins. Using bruised or infected veins will
prolong the inflammation process and so should also be avoided.
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services
Page 29 of 34 CF & SMcK August 2009
29 Appendix 6 PERIPHERAL LINE INSERTION – REVIEW TOOL
Ward………………………………………………………………… Date………………………………………………………………….
Observation Clinical Hand Personal Sterile field, Skin cleaned Semi- Safe Hand Intervention All elements
indication hygiene prior protective e.g. dressing with 2% permeable, disposal of hygiene post documented performed
equipment towel Chlorhex- transparent sharps
idine dressing
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
1
2
3
4
5
6
7
8
9
10
Total
Number of
observations
Total number
of
observations
where
compliance
achieved
%
compliance
Name……………………………………………………………. Signature ……………………………………………………………
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services Page 30 of 34 CF & SMcK August
2009
PERIPHERAL LINE CARE – REVIEW TOOL – CONTINUING CARE
Ward………………………………………………………………… Date………………………………………………………………….
Observation Continuing Site Dressing Line in- Hand Personal Sterile Ports New Safe New line Interventi All
clinical inspected intact situ > 72 hygiene protectiv field, e.g. cleaned syringe disposal if on elements
indication hrs prior e dressing with 2% for each of sharps required documen performe
equipme towel Chlorhex flush t-ed d
nt -idine
Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
1
2
3
4
5
6
7
8
9
10
Total
Number of
observations
Total number
of
observations
where
compliance
achieved
%
compliance
Name……………………………………………………………. Signature ……………………………………………………………………………..
Clinical Guidelines and Procedures for Peripheral Intravenous Cannulation In Adult and Children Services Page 31 of 34 CF & SMcK August
2009
30 Equality Impact Assessment
Equality and Health inequalities Impact Assessment Screening Checklist
Name of policy/service Peripheral intravenous Cannulation clinical guideline and
procedures
Is this a new or existing Review of existing policy
policy/service
Purpose of the policy/service To provide guidelines to staff to ensure quality of practice
Stakeholders in policy/service See validation grid
development
Person responsible for policy/service Caterina Falce and Steve McKenna
impact assessment
Proposed date for implementation of August 2009
policy/service
Do you think the policy/service will impact upon any group within the population based upon:
Race/ethnicity No Lower socio-economic groups No
Gender No Involvement in the criminal justice system No
Religion/belief No Homelessness No
Disability (including long term No No
conditions and mental health) Looked after children
Age No Population groups more at risk of developing No
certain conditions (based on community
health profile data)
Sexual orientation or gender identity No Any other groups No
What impact will the policy/service have on lifestyles? For example:
Diet and nutrition
Exercise and physical activity
Substance use; tobacco, alcohol, drugs
Risk taking behaviour
Education and learning or skills
Functional ability
Quality of life
Will the policy/service have any impact on the social environment? For example:
Social status
Employment (paid or unpaid)
Social/family support
Stress
Income
Will the policy/service have any impact upon:
Discrimination?
Equality of opportunity?
Relations between groups?
Improving uptake of services by under represented groups?
Will the policy/service have any impact on the physical environment? For example:
Living conditions
Working conditions
Pollution or climate change
Accidental injuries or public safety
Infection control
Will the policy/service impact on access to and experience of services? For example:
Healthcare
Transport
Social services
Housing services
Education
Caterina Page 32 19/01/2011
Equality impact assessment screening checklist summary sheet
1. Positive impacts (Note groups affected) 2. Negative impacts (note groups affected)
Promotes good practice for all groups. None – no negative impacts currently but will
monitor and review in one year.
3. Additional information/evidence required
Data collection across equality strand groups.
4. Recommendations
5. As a result of completing the impact checklist, have any negative impacts been identified, and if so
is a full impact assessment recommended?
No – policy promotes good practice.
6. If impact assessment has not been recommended please state the reasons why.
Data collection and validation required.
Date for completion of screening checklist review /completion of full impact assessment :
Managers name and signature: Date:
Steve McKenna 09/09/09
Caterina Falce 09/09/09
Approved by Operational manager for Equality Date:
and Diversity(name and signature)
Jennifer Kenward 04.11.09
Caterina Page 33 19/01/2011
Caterina Page 34 19/01/2011
